Opportunity-cost analysis and mass preemptive smallpox vaccination

Ross at the Bloviator links to and comments on a New York Times story about the damage being done to other public health initiatives by the costs of defensive moves against bioterrorism, including the Phase I smallpox vaccination campaign.

As noted before in this space, I can’t see either the financial cost or the side-effects burden as an adequate reason not to proceed with mass vaccination at once. [By “at once” I mean, ideally, before mid-February, when the war against Iraq is scheduled to start: just think about what happens when you hit a skunk with your car. (Yes, I understand it’s already to late to get that done.)] A few hundred lives and a few billion dollars simply aren’t large stakes compared to the damage that would be done by big smallpox outbreak.

But the “opportunity cost” argument is much more potent. If the result of going all-out to prevent smallpox is to leave ourselves more vulnerable than we would otherwise be to anthrax, or alternatively to increase the incidence of tuberculosis and syphilis, those costs could easily outstrip the direct financial costs and side-effects burdens of vaccination itself. That is, mass smallpox vaccination might be cost-justified but not cost-effective compared to other uses of the same public-health dollars.

However, that analysis implicitly assumes that the public health budget is more or less fixed. Now that I’m paying a little bit of attention to this issue, it seems clear to me that the weakness in our public-health machinery constitutes a significant national vulnerability. If we’re at war, then we ought to be shoring up all of our defenses. The money could come from other defense expenditures (missile defense, for example), from other “homeland security” measures (airport security?), from non-defense expenditures (pick your own), from taxation (a spending increase is at least as good as a tax cut if the goal is short-term economic stimulus), or from borrowing (i.e., increasing the deficit).

As a born-again deficit hawk, the last listed would be my last choice, but a few billion bucks in a ten-trillion-dollar economy simply isn’t a sum worth worrying about in this context. No one really thinks that the $60 billion or $100 billion or $200 billion it’s going to cost to conquer and occupy Iraq is a serious argument against doing it. So why does a much smaller sum for domestic preparedness suddenly look like a budget-buster?

There’s a different version of the opportunity-cost argument, but it’s subject to the same response. Right now, we have limited amounts of vaccine, and limited amounts of vaccinia immunoglobulin (VIG) to treat vaccination side-effects. Mass vaccination now would exhaust the vaccine supply, leaving none for post-attack vaccination of those exposed to infected individuals, and more than exhaust the available supply of VIG. That’s a problem. But how big a problem depends on how much it would cost to rapidly increase the supplies of vaccine and VIG, where “rapidly” means wartime-rapidly, not medical-research-and-development-rapidly.

Let me repeat: Mass smallpox vaccination now may not be the right thing to do. But the arguments I’ve heard against it so far seem either altogether invalid or arguments for doing something else as well to relax some constraint in the problem: increasing the total public health budget, rushing production of vaccine and VIG.

And to repeat again: odds are, this is all about a precaution that will turn out to be unnecessary. Most precautions do. That doesn’t make it prudent to forgo them.